Though essential, there are many bad effects with salt when taken in large amounts over a long period of time. The kidneys cannot get rid of this in time which leads to water retention, hypertension ( raised blood pressure) and studies have shown this is also important in development of osteoporosis among women even with normal calcium levels.
Processed or canned food contain salt in plenty. These may not taste salty.
Fat free or low fat food usually have high sodium content.
Tricks to give a salty taste without really adding salt are to use vinegar or to squeeze lemon on to the dish.
Rock salt gives the taste of salt but is very low on sodium content.
Sodium content in some commonly used foodstuff:
- A teaspoon of light soya sauce has 365 mg salt.
- Dark soya sauce has 200 mg in a teaspoon
- Reduced salt soya sauce has 185 mg in a teaspoon.
- A small cup of French fries has between 200 to 400 mg salt.
- Chicken rice has a whooping 1290 mg salt !!
- A glass of milk (250 ml) has 80-120 mg salt.
Did you know?
One level teaspoon of salt is the equivalent of 2300 mg of sodium
Reducing the salt by 3000 mg a day can reduce the risk of developing a heart event , stroke and death by any cause by phenomenal percentages.
Salt is seen in these forms. Look for these on the nutrition labels.:
• Monosodium glutamate
• Disodium phosphate
• Sodium citrate
• Sodium nitrite
• Sodium nitrate
• Sodium benzoate
• Sodium ascorbate
• Baking powder
• Baking soda
These are salty…….
- Salt and seasoned salt (or salt seasonings)
- Boxed mixes of potatoes, rice, or pasta
- Canned meats
- Canned soups and vegetables (with salt)
- Cured or processed foods
- Ketchup, mustard, salad dressings, other spreads and canned sauces
- Packaged soups, gravies, or sauces
- Pickled foods
- Processed meats: lunch meat, sausage, bacon, and ham
- Salty snack foods
- Monosodium glutamate or MSG
- Soy and steak sauces
Glycemic index ( GI )of a food is the increase in blood glucose ( above fasting glucose) 2 hours after ingestion of a constant amount of food divided by a reference food( usually glucose).
To make this easy to understand, if the GI of a particular food is 72, this means that 72% of the ingested food is converted to glucose within the body after 2 hours of consumption.
GI reflects the rate at which carbohydrate is absorbed and digested by the body. Try to aim for low GI food combined with medium or high GI food rather than have more of high GI food. Whatever be the diet chosen, the dietary management has to be combined with physical activity for maximum benefit. A diet which suits one person may not suit all. It is advisable to see which food increases the sugar levels by checking the sugar levels after each food ( this is painful, but this can help to decide which food suits a person).
Low GI food stuff with the GI levels
Yoghurt low fat 14 Milk chocolate 24 Multi grain bread 48 Broccoli 15 Spaghetti 27 Parboiled rice 48 Celery 15 Skimmed milk 32 Carrot juice 45 Bell peppers 15 Fat free milk 32 Jams and marmalade 49 Spinach 15 Apple 38 Low fat ice cream 50 Tomato 15 Plum 38 Orange juice 52 Soya beans boiled 16 Pears 38 Kiwi 53 Artichoke 15 Apricots dried 31 Banana 54 Asparagus 15
Black beans 41 Sweet potato 54 Cauliflower 15 Boiled lentils 29 Egg plant 15 Boiled kidney beans 29 Lettuce 15 Green beans 15 Peanuts 15 Cucumber 15
Medium GI food with their GI levels
Oat bran 55 Rye-flour bread 64 Rice, brown 55 Apricots (tinned in syrup) 64 Fruit cocktail 55 Raisins 64 Spaghetti, durum wheat 55 Macaroni cheese 64 Popcorn 55 Beetroot 64 Muesli 56 Mars bar 64 Mangoes 56 Black bean soup, tinned 64 Potato, boiled 56
Cake , tart 65 Mini Wheats (wholemeal) 57 Potato, steamed 65 * Table sugar (sucrose) 65 Apricots 57
Barley, flakes 66 Potato, new 57 Pineapple 66 Digestives 58 Rice, white 58 Croissant 67 Pizza, cheese 60 Ryvita 67 Hamburger bun 61 *Ice-cream 61 Whole meal bread 69 Shredded Wheat 69 Muffin (unsweetened) 62 Potato, mashed 70
High GI food with their GI levels
White bread 71 Broad beans 79 Golden Grahams 71 Jelly beans 80 Millet 71 Pretzels 81 ** Watermelon 72 Rice Krispies 82 White rolls 73 Potato, micro waved 82 Puffed wheat 7 Cornflakes 83 Corn chips 74 Potato, instant 83 Chips75
**Potato, baked 85 Rice pasta, brown 92 Doughnut 76 Wafer biscuits 77 ** Rice cakes 77
** low in calories and highly nutritious
* empty calories
Did you know that every ten seconds a person dies from diabetes related complications?
Diabetes is the fourth leading cause of global death by any disease.
Remember that heart problem is the number one cause of death among those with diabetes. It is said that a person does not die of diabetes, but instead of the heart ailment. The presentation can be just as a spasm of the blood vessels supplying the heart muscles or a frank attack where the blood vessel supplying the heart muscle is blocked completely or the heart may be enlarged.
The pain normally associated with heart attack is absent for those with diabetes. Hence, any “simple” chest discomfort may warrant a heart check up rather than treat it as simple gastritis or “gas”. Sometimes the discomfort may travel down the left arm, neck, back or to the shoulder. If the discomfort is associated sweating and faintness, consult with your doctor immediately. There are many tests that the cardiologist( doctor who specializes in heart diseases) will order for.
Control of the blood pressure and lipids are more important to prevent a heart attack. Sugar control is not all that important to prevent an attack, though. There are medicines which may have to be started by the health care professional to prevent such a calamity.
An ECG ( electrocardiogram) is done with patient in resting state and can tell if an ongoing chest pain is related to the heart or not or if a previous episode of chest discomfort was from the heart. It also tells about the rate.
An ECHO cardiogram is also done either in resting or under some form of exercise. This shows the size of the chambers of the heart, the dimensions of the valves, the blood flow and other parameters.
A Treadmill test will show how the heart copes with exercise. Patients with problems in their back bones or knees cannot do this test unless under supervision. Changes in the heart rate, rhythm , blood pressure may be noted which can point towards a block in the coronary vessels.
A coronary angiogram is a test done to map the coronary vessels. This is done by either introducing a tube through a vessel in the thigh or through a normal cannula in the arm. A dye is injected and films are shot. Blocks can be seen which are interpreted by either the radiologist or cardiologist. The blocks can be stented or ballooned or operated depending on the site and number of blocks.
The doctor will check the kidney function periodically to check if there is the beginning of kidney disease. Reduction of urine output and swelling of the face, body and feet with losing consciousness is a late feature. The presence of microalbumin in urine is an early feature which needs treatment. However, having menstrual periods, a mild urinary infection, having exercised just prior to giving the sample or having fever, the levels of microalbumin can be high. The health care provider will determine if another test is to be repeated. With proper control of sugar, blood pressure the levels improve. Some need medications to help reduce the levels.
Sometimes , dialysis or transplantation is needed when the kidneys reach a terminal stage. Consult with your doctor regarding the diet to be followed if there is such an event. You may have to consult a nephrologist( specialist in kidney diseases).
This is probably the most important of all the organs as far as we all are concerned. What is the use in living, if your eyes are not working or you are blind? Diabetes is the commonest cause of preventable blindness. One would never enjoy the beauty around us and the marvels of the Almighty if it were not for the eyes. Strangely even with good eyesight, we sometimes do “not see” the marvels of God.
Most of the people decide to meet the eye doctor when their eye sight is quite bad…. Till then most meet with the optician who checks the power of the glasses and they are happy.
Good control of sugar can prevent the onset of eye disorders. High blood pressure can also damage the eyes. Being a smoker too can affect the eye sight. It is generally believed that eye sight will become poor with advancing age due to onset of cataract (clouding up of the lens) , Being a diabetic can even make a young patient susceptible to development of cataracts.
The ophthalmologist( the doctor who specializes in eye diseases) will check the pressure in the eyes, look for cataract and also for the retina after instilling drops in the eyes. The eyes will be out of focus for close to an hour or two after the test. Remember checking the power of the eyes is not the test for diabetes check up. Close to 70% of the retina will be damaged before problems arise in vision. It is important to prevent these complications from arising by having an annual checkup with your eye doctor.
Changes in sugar levels can affect the clear fluid in which the lens is bathed in the eye. Thus there is a blurred vision which many people compare to a curtain kept in front of their eyes. The clear fluid becomes turbid when high sugar levels occur and then clears up when the sugar level normalizes. It is, therefore, important to mention to the eye specialist you are diabetic and whether under good control or not. It is wise to have new reading glasses when the sugar levels are normal.
When to meet the eye doctor?
• Blurred vision
• Trouble reading
• Seeing double
• Injury to eye
• Spots or floaters in the eyes
• Eyes get red and itchy
• You cannot see things on the outside of your eye vision field.
Know your eyes
The eyes are your mirror to the outside world. The eyes are covered by eye lids protecting it from external trauma or injury. This also prevents the eyes from drying out. Light enters through the cornea and travels through the center of the iris, which is the colored part of the eye. Light then falls on the retina situated at the back of the eye which then converts these signals to signals which can be read by the brain and is transmitted through nerves to the brain for us to understand what we are seeing. All this happens in fractions of seconds …
Know some terms
Glaucoma: This is term used when the pressure in the eyes increase. This can happen in those with a longer duration of diabetes. The vision of the eye is gradually lost. The eye doctor will perform tests which will determine how severe it is and will prescribe either eye drops or surgery.
Cataract: This is term used when the lens becomes cloudy. Normally elderly people get cataracts even without being a diabetic. Cataract may occur in younger adults if they are diabetic. The eye doctor will advise what to do after checking for cataract. For some people the retinopathy will become worse if treated for cataract and for some glaucoma may develop.
Retinopathy- this is term used to mean damage to the retina, the nerve layer of the eye. About 70 percent of the retina has to be damaged for one to show changes in eye sight. By this time, it will be so severe, complex treatment plans will have to be made with outcomes resulting in compromised vision. The small blood vessels in the back of the eye balloon out and may form pouches. They may start leaking. This may cause swelling of the nearby parts of the eye and even cause a lifting up of this layer, called retinal detachment. The eye doctor will advise how to get treated depending on the stage the eyes are.
Often, this is the most neglected of all the body parts. It has been studied that women care more for their feet than men. It has also been shown in studies that the foot problems are less among the muslim population due to the washing of their feet for prayer 5 times a day. One should pamper the feet at night daily.
The feet may swell up ( due to high blood pressure, kidney disease, the effects of the medicines you are given, or heart disease). You may notice the skin becomes dry (which can cause itchiness), the nails can get deformed, you may notice white rashes between the toes, decreased sensation to hot and cold and small wounds go unnoticed unless pointed out by somebody.
You have to inspect your feet daily with a mirror, apply moisturizing cream to the top and bottom of the feet ( avoid the areas between the toes), trim the toe nails straight ( taking care not to cut the corners), use one size extra shows or footwear, avoid narrow footwear, use loose cotton stockings, check the inside of the shoes daily and wash your feet daily, but dry them properly. Never cut calluses( thickened skin) yourself as it will risk injury.
The doctor will usually check the pulsations of the feet blood vessels, check for temperature sensation, check for fine sensation with a thread and the reflex at the ankle. You may need to have custom made footwear in some cases.
Remember to show the doctor for any wounds or cracks or ulcers that may develop. Remember that any infection can spread rapidly in diabetic patients which may sometimes need an operation resulting in loss of limb. Coupled with smoking, diabetes is dangerous combination.
Sometimes the legs may ache while walking or may have cramps at night. This can be the starting feature of a nerve problem. Consult your doctor if this happens.
Get educated. One key to preventing diabetic skin problems is to understand what causes them. Talk to your doctor. Learn about diabetic skin complications, what your particular risks are, and how you can lower them.
Control your diabetes. Controlling the blood glucose within normal range can go far toward preventing common diabetic skin complications.
To get a handle on your diabetes, strive for a healthy weight, eat right, cut back on salt, maintain a healthy blood pressure, and exercise. That’s a tall order, but talk to your health care team for support.
Be aware. If you suffer from diabetic nerve damage (neuropathy), you can have an infected cut, scratch, or skin puncture and not know it. Don’t let a small problem turn into a big one .Check your feet, ankles, in between your toes and legs regularly for wounds that aren’t healing.
Do something about wounds and sores. Don’t neglect wound care. If you find a nick, a scratch, a small cut, anything that isn’t healing or that worries you, talk to your doctor immediately.
Cover up. This simple first line of defense can help you avoid the cuts and scratches that can lead to infection. Whether you’re gardening or walking the dog, cover your legs with long pants and your feet with flat, good-fitting shoes.
Practice good skin care. Keeping skin clean and dry, but not too dry, is key to good diabetic skin care.
Keep skin comfortably dry, especially at armpits, toes, and groin. Talcum powder can help.
But avoid drying skin out. Skin that’s too dry can crack, itch, and get infected, so prevent that by taking short, lukewarm showers or baths and using mild soaps and shampoos when you wash. Avoid deodorant or scented cleansers, which can be harsh on sensitive skin.
Moisturize if your skin is dry . The best time to moisturize is right after a shower or bath, when skin is still moist.
Dry well by patting gently — don’t rub — focusing on underarms, between legs, under breasts, and between toes.
Diabetes and teeth
This is probably the most neglected of the various aspects of ones body. Many are unaware that care of the mouth is as important as looking after the eyes, feet or heart when one has diabetes.
Some presentations will be :
• Slow healing time after dental procedures
• Fungal infections coming very frequently( white patches)
• Dry mouth
• Cavities in the teeth
What can be done to minimize the risk
• Brush your teeth after every meal and floss the space between the teeth at least once daily.
• Use oral antibacterial rinses to wash away the germs
• Meet the dentist at least yearly once.
The gums ( pink tissue on which the teeth are embedded) can become soft, spongy and start bleeding. Later on the gums may detach themselves from the teeth causing them to have pockets. These pockets can harbor organisms which can erode into the underlying bone and can cause the tooth to be loose. The infection may spread at an alarming rate that you may have to be hospitalized and the infection can even spread to as far as the brain through the rich network of blood vessels on the face.
High Blood Pressure ( Hypertension)
Blood pressure has 2 values- a systolic ( the reading at top) and a diastolic ( reading at the bottom). This is checked at every visit to the doctor by a machine called sphygmomanometer. The most accurate one is the one using mercury( which are rare these days). Often, digital and air driven machines are used and freely available for use at home or office. Normally the blood pressure can be high when consulting with the doctor( due to anxiety). If found high, recheck either at home first thing in the morning and before going to bed for a week. Show the readings to the doctor for making a decision. Alternatively, a machine can be left attached to the body which will record the pressure for a week during the days for varying periods up to a week. The average of those readings will determine of you are having high blood pressure or not. This can help detect blood pressure fluctuations while asleep. Most of the serious side effects of high blood pressure ( heart attacks and strokes) are in the early hours of the morning after midnight.
If found to have high blood pressure, the doctor will advise you to cut down on salt intake. (Pickles, sauces, tinned vegetables, ketchup, salted butter, sausages and hams all contain salt in excess) Besides this, you will be asked to reduce the consumption of red meat, fried food, smoking and alcohol. You will also be advised to increase intake of fruits and vegetables. The doctor will advise you to
Try out relaxation methods. This may vary from person to person- such as dancing, listening to music, playing golf, walking, reading, gardening, painting, yoga classes, swimming and so forth. ALCOHOL and SMOKING DO NOT FORM HEALTHY RELAXATION TECHNIQUES!.
The normal blood pressure is < 130/80 mm Hg. Even reducing the pressure by 20/10 mm Hg has significant benefits on the various organs such as heart, eyes, kidneys and brain. Very often, more than one medicine may be needed to control the blood pressure. Sometimes the doctor has to prescribe blood pressure medicines to control the leak of protein in the urine though the blood pressure reading will be normal. Most of these medicines help to protect the kidneys and heart as well. The blood pressure will never reach zero as the body will take measures to correct itself. Only 18% of the diabetic patients reach the target goal of blood pressure.
Bariatric surgery is known to be the most effective and long lasting treatment for morbid obesity and many related conditions, but now mounting evidence suggests it may be among the most effective treatments for metabolic diseases and conditions including type 2 diabetes, hypertension, high cholesterol, non-alcoholic fatty liver disease and obstructive sleep apnea.
People are often reluctant to undergo surgery for fear of pain and the possible scars on their body. Some buy time by dieting and doing other herbal cures. These may last for a short time and the weight loss may rebound in a short period. The weight loss will not be permanent in these methods.
- Please be informed that this is not useful among those with type 1 diabetes in curing diabetes.
- Bariatric surgeries help in almost full cessation of medicines for diabetes type 2, blood pressure and cholesterol after the surgery. Of course, one may have to take a multivitamin tablet or an iron tablet after the surgery.
- This will be done only of the BMI is >40 or >30 with other medical problems.
- Please be reminded that not all people who are overweight or obese will benefit from the surgery and so also some not so obese people will benefit from this surgery to help adjust their metabolic dysfunction thereby improving their quality of life.
Work up prior to surgery
Normally all fat people will carry some risk for surgery as they will have many associated problems. A thorough medical check up is normally done which will include blood tests, chest X ray, spirometry to check the lung function, a detailed heart check up , a check up by the anesthetist ( doctor who puts you to sleep during the surgery) and the dietitian. Normally the patient , after medical check up, will be admitted the night before the surgery and be discharged the day after the surgery after performing an X ray to check for leaks ( you will made to drink a medicine and then X ray will be taken). Normally the person can go for work in office after 5 days. This is a procedure done by laparoscope and so pain is very much reduced.
Types of surgeries:
There are two main types of bariatric surgeries – Restrictive and malabsorbptive. “Restrictive” means reducing the size of the stomach that prevents the patient from eating more than a small amount of food. “Malabsorbptive” means that the patient eats normally but the carbohydrate and fat are not absorbed from the gut leading to loss of weight. The common three operations done for obesity all over the world are Gastric Banding, Sleeve Gastrectomy , Mini bypass and Gastric Bypass.
Gastric Banding –
In this, a PVC band is applied to the uppermost part of the stomach to restrict the size of the stomach. Thus there is an artificially small gastric pouch. When the patient takes more than a little food, he feels full rapidly and if he eats more he feels like vomiting. This will need frequent filling up of the band to narrow the opening. It can be relaxed as well when needed. This is not much of use in the adult population these days.
Sleeve Gastrectomy –
This operation utilizes a series of staplers to run across the stomach to restrict the size of the stomach, to convert it into a tubular structure. The great advantage of this operation is that it does not require frequent adjustments like the gastric band does. Also it is quite easy to perform in experienced hands, and the time taken for surgery is also not much. The average weight loss after sleeve gastrectomy is about 25-30 kg. Depending on the excess weight an individual has, it can be more. In other words, several patients have lost about 50-80 kg after this operation!
Gastric Bypass –
It is a more complex operation which bypasses the second half of the stomach by connecting the first half of stomach directly to the intestine. Although this is a technically challenging operation compared to the sleeve gastrectomy, it is more useful in obese patients who are also diabetic, hypertensive, and have cholesterol and triglyceride problems. However the major issue with gastric bypass is the need to take calcium, iron and vitamin B12 supplements as the nutrients are not absorbed sufficiently following this operation.
A Mini Bypass
This is also in practice now.
The common fear is whether these operations carry any major side effects. As far as the sleeve gastrectomy is concerned, the major side effects are in the immediate post operative period, when the surgeon worries about a possible leak. This happens only in a tiny proportion of patients, that too those who are very fat, in the region of around 200 kg. Even in such patients, in the last year or two special devices have been introduced to support the stapler line and prevent leak. Thus with each passing year, these operations are becoming safer.
The era of bariatric surgery questioned is over, it is now accepted with nearly over forty lakh patients having undergone this surgery from all over the world. With this background, it is best to use it judiciously to make patients lose weight, take control over their diabetes, hypertension, and live healthy long lives. (One study showed that on an average patients live 15 years more after performing bariatric surgery) The sun has not set on Bariatric surgery. It has just risen.
These metabolic surgeries are being done to help control the weight and even get rid of diabetes, hypertension and increased lipids. But, it needs the person to be motivated for the rest of life to keep the beneficial effects of the procedure. These can cost quite a lot, but can be tried to contain those who are extremely obese and or dependent on just too many medicines for their metabolic control.
The surgery will help reduce the intake of medicines for blood pressure, diabetes and high blood lipids, which will make the patient feel much better than having to take so many medicines.
The success of the surgery will depend largely up on the determination of the patient and the ongoing effort by the patient to adhere to the instructions given by the medical and surgical team. One will have to adhere to a diet pattern during the post operative phase. The patients will have to be on a lifelong supplement of vitamins and some on iron as well.
Liposuction removes the subcutaneous fat and not the visceral fat. So, it may help in better look, but the dangerous visceral fat will remain as it is.
What is metabolic syndrome?
This is a condition in which excess body fat is collected and deposited on the body which has an adverse effect on life. Those with metabolic syndrome have the following as well:
- High Body mass index
- High blood pressure
- Polycystic ovaries
- High blood lipids
- High waist circumference( >90 cm in males and >80 cms in females)
- Sleep disorders
- Fatty liver
Those with metabolic syndrome are prone to develop the following:
- Type 2 diabetes
- Coronary heart disease
- High blood pressure
- Cancers of the endometrium (inner lining of the uterus), colon and breast.
- Mental disorders
- Sleep disorders( sleep apnoea)
- Liver and gall bladder disease
The management will need the support of many specialties including even a psychologist opinion.
This is a state of disillusion, frustration and a meek submission to diabetes which results in complete disregard to blood sugar level management. This is regarded as “freedom” from this confusing , frustrating and ever demanding condition. This is often seen many years after commencement of treatment.
This burnout is usually accompanied by varying levels of stress, anxiety, depression and labile emotions.
- Scared of living with diabetes
- uncomfortable social situations- cannot swim, cannot party, cannot be out for late night meetings, cannot do this or that…
- overwhelmed and angry with diabetes
- feeling “alone”
- Feeling diabetes is taking too much of mental and physical energy
- Food deprivation
- concerns about the future- “Can I marry?”, “Will I be able to conceive or have a normal sexual life”, “How long can I live?”
The commonest modes of presenting can be:
- Self destructive behavior
- Eating or drinking whatever one wants knowing fully well it is not good for those with diabetes.
- Improper insulin shots or lying about medicine intake
- Improper maintenance of log books
- Fabricating glucometer readings
- Complications of diabetes can set in which in turn makes things worse to a point of suicidal behavior.
How to overcome a burnout?
- Stay focused and motivated. Do not attempt to be perfect- forgive those occasional high sugar levels if other readings are fine.
- Identify barriers to care of diabetes and resolve them.
- Edit negative thoughts
- Enroll into support groups
- Speak with a friend or health care professional
- Rethink exercise schedule
- take a break
- Laugh it off
A check list:
Ask yourself whether you have done the following:
• Enough medicines are there with you.
• Have you had the blood tests for cholesterol, liver, kidney, hemoglobin , urine for protein, sugar and 3 month average of sugar at least once in the past 6 months.
• Have you had a foot check , an eye check by eye doctor and a heart check such as having an ECHO cardiogram and Treadmill test in the past one year. There are instances when the treadmill could not be done due either being overweight or having knee or back problems.
• If an elderly male, have you had a PSA test done in the past one year ( this is a blood test for the prostate) Alternatively, you could meet with a Urologist, the specialist for these problems.
• If an elderly male or female, have you had the calcium, vitamin D levels checked in the past year and a bone mineral density which is a scan for the bones showing if they are prone for fractures. Vitamin D levels, if very low, will need a correction with medicines and a recheck done depending on the doctors advice.
• Women after the age of menopause or those with a strong family history of cancer of the breast should have a mammogram ( special X ray of the breast) done once yearly.
• Thyroid levels can be checked yearly once , unless on treatment.
• Distended abdomen, “gaseous feeling” and belching with a mild upper chest discomfort can sometimes be a marker for something sinister. Have a gastroscopy done to make sure there are no ulcers.
• All bleeding from below is not from ‘piles”. It may also be worthwhile to have a colonoscopy done.
• Have you been monitoring your progress and if you can see no improvement in either the sugar levels or weight, you must seriously reconsider your options. Please do not always find fault with the doctor or the medicines, the reason could be elsewhere.
• Have you got the glucometer serviced or checked out especially if more than an year old
• Have you shown the Insulin delivery devise to the doctor once a year if the refilled pens are being used. Faulty devices can lead to errors in dosing.
• All said and done, there is no point in doing an annual whole body scan to make sure all is well. There are so many things which may go unnoticed and also will be risk of too much of radiation.
• Please check the footwear daily for wearing out or foreign bodies. They can prevent serious mishaps later.
• Have you had an annual Flu vaccine? This will reduce the flu which occurs while traveling a lot
• For those above 65 years of age a pneumococcal vaccine is useful. This is to be taken just once in a lifetime.
Once we are born, we all have to die someday. During the course of our life, we learn a lot from our experiences, sometimes we do not. We all wish to live longer and age gracefully. You may recollect that our grandparents lived longer and healthier. This is largely due to reduced stress levels, natural unprocessed food, more of physical activity and less dependent on automated gadgets or electronic gadgets.
Ironically, people of today look for shortcuts to everything for example weight reduction surgery, face lift surgeries various plastic surgical techniques to help beat natural aging and also gadgets which can remotely control everything in life from opening the gates, switching on the lights, locking the house and what not. Who knows, maybe in the near future we may even have drive in hospitals where you drive into the OPD room, speak out your symptoms into a machine , get a token, have blood drawn for tests and have the doctor give the medicines at another counter.( like as in Mc Donalds drive through)
Life has indeed become so fast, we hardly have the time to stop and think of ourselves. There are so many age defying cosmetics flooding the market these days.
Many people with diabetes live to a ripe age by leading a healthy lifestyle and regular check. However, some are lucky not to have diabetes until their middle years, but become diabetic after 65 years or more. In a study around 7% of the older adults were diagnosed as having diabetes by noting high fasting sugar, whereas 6% were diagnosed based on their post meal sugar levels.
Common changes with advancing age
Glucose intolerance increases and slowing of the glucose absorption occurs with advancing age. There is a decline in lean body mass, there may be an increase in body fat due to increasing insulin resistance. There may be a decline in level of physical activity.
The medicines that were once doing well in controlling sugar levels may not work as effective as age advances.
Older adults may not perceive hunger and may not feel thirsty as well. Digestion becomes delayed. Bowel habits may not be regular as before. Skin may become dry. The response to low sugar levels are much slower as age advances. Low sugar levels may manifest as confusion and dizziness. Tremors and sweating are not common.
- Reduced vision, reduced mobility and memory loss is also common. Mistakes while dosing the medicines are also common.
- Complication of the eye, nerve and kidney is directly linked to the level of sugar control. Maintaining good levels can delay the onset or progression of the above complications.
- However, heart diseases stroke, and blood vessel problems are directly linked to the control of blood pressure and cholesterol panel. This is one reason why doctors prescribe medicines for cholesterol even when the levels are normal.
- With advancing age, any of the above complications are possible. The recovery from the complications will not be as smooth as when coming at a younger age.
- Some need assistance while walking such as a physical support or a walking stick. The floor in most of the places has a smooth surface and planting the feet is quite a hazard.
- Most of the time, older adults feel embarrassed to address their fears to their dependents. They may feel better to mention those to their healthcare providers. This is quite normal
There are not many studies involving older adults. However, based on some of the studies, the following are applicable:
- Sugar levels between 7 to 8.5 mmol/L is acceptable
- Blood pressure ≤ 140/80 mm Hg
- Total cholesterol ≤ 5.2 mmol/L
- HbA1C ( the three month average of sugar ) is not reliable in older adults as red cell span may be reduced with advancing age. Diseases of the kidney and liver may affect the value.
However, the levels of blood sugar and 3 month average are not to be as stringent as for that of a younger person.
Increase in urine output may be due to urinary bladder irritation or dysfunction, medications for reducing blood pressure or due to prostate enlargement in males and not always due to high blood sugar levels.
Low sugar levels can mimic having a fit or stroke.
- The check up for the older adults must be more regular and frequent. The annual eye, heart check and foot check may have to be done more frequently if there are minor problems.
- Assessment of the kidney function is made by blood tests which may show changes. This can be tackled if checked for.
- Care of the feet may need heel protection, extra cushioning of wheel chair of bedding and prevention of dry skin is important.
- Driving at this age may be troublesome due to the reduced vision, reduced judgment and reflexes.
- Have the calcium, vitamin D levels checked as well as the bone mineral density. Older men have to be assessed for prostate as well.
- Make sure the older patient above 65 years must have taken a vaccination against pneumonia once and a vaccine against flu yearly.
- Many of the older adults may be having medicine such as diuretics ( which increase urination), hormones such for post menopause or steroids , and anti depressants which may worsen sugar control.
- Maintain good oral hygiene, check the feet, the skin folds for fungal rashes and boils which may go unnoticed by the patients.
- Make sure the bowels move once a day as constipation is very common.
The consultation with the health care professional:
- It will be useful if a small handbook can be used for mentioning their concerns as they may forget during the consultation.
- Maintaining a log book of the sugar readings and a diary of food intake will help to make inferences and plan management.
- The consultation can take more time than normal making the patient understand what is expected.
- The waiting period can be a problem as well. It will be worthwhile to have the blood and urine samples drawn early and they can have a light snack while waiting for their turn.
- Most of these adults are on many medicines and so may have gastritis.
- It is worthwhile to have a check by Gastroscopy ( a tube inserted through mouth to see if any ulcers in the stomach) or colonoscopy( tube inserted through anus to look for any problems down below)
- It sure pays to empathize with the elderly. They need the love and attention.
- Exercises in this age group are to be carefully planned.
- For those with eye problems or after laser treatment, it is advised to avoid intense exercises which may further increase the pressure.
- For those with neuropathy, it is advisable to perform exercises such as walking or cycling. Be careful of weight lifting.
- Jogging and swimming can be done if they have been doing the same routine over the years.
- However, get the doctors advice and clearance before planning a regime.
- Any exercise in water is useful and safe for the joints. It helps to burn calories as well.
- Walking together in groups or even performing aerobics, Yoga or Tai Chi also help in a better way as combining enjoyment with exercises make this pleasurable and motivated to continue with this. Yoga, meditation also help in relaxation.
The aims of management:
- The management of older adults involves avoiding low sugar levels, avoiding weight gain or loss in excess and to maintain well being.
- Metformin, gliclazide, Vildagliptin and Sitagliptin are safe to use among the oral medicines.
- Insulin is safe if used sensibly. The advent of pen devices has helped the patient care. It allows accurate dosing and gives audible clicks while dialing the dose. Using the bottle of insulin and syringe may be clumsy at times and can give erroneous dosing which can be quite a headache.
- It is better to have simple treatment plans rather than complex regimes difficult to remember.
- The patient care given, the patient care giver, the patient care process and the patient care outcome are very important in the management of this elder population.
In todays world,one needs to relax in between to recharge ones mental and physical faculties. Just being a diabetic should not ruin your chances for a pleasurable trip.
See Your Doctor Before You Go
Before a long trip, have a medical exam to make sure your diabetes is in good control. Schedule the exam with enough time to work on your control before you depart. Get immunization shots — if you need them — at least one month before you leave. If the shots make you sick, you’ll have time to recover before your trip. Some countries do insist on some vaccinations which are mandatory. Most of the vaccines are available at the Tertiary care centers here in the Sultanate. They will issue a vaccination card as well which you may have to produce at the port of entry.
You might be needing a letter stating you are carrying the insulin shots, the glucometer kits, syringes and the pump in your carry bag. The site www.OneBag.com will help. The site diabetesaliciousness.blogspot.com also helps in knowing rules at airports around the world.
Before any trip, get two papers from your doctor: a letter and a prescription. The letter should explain what you need to do for your diabetes, such as take diabetes pills or insulin shots. It should list insulin, syringes, and any other medications or devices you use. The letter should also list any allergies you have or any foods or medications to which you are sensitive.
The prescription should be for insulin or diabetes pills. You should have more than enough insulin and syringes or pills to last through the trip. But the prescription may help in case of emergency. It may be useful to have a prescription in the language of the country you are visiting as English is not widely spoken or understood in some parts of the world. The sites https://translate.google.com as well as packitup.com give an idea how to do this translation.
It is safer to have enough stock of the medicines with you. It will be cumbersome to hunt for a doctor and schedule an appointment in the middle of enjoyment. This can even ruin your vacation. Carry enough stock of batteries for the glucometer or pump.
Prepare for an Emergency Abroad
No matter where you go, wear a medical ID bracelet or necklace that shows you have diabetes. If you’re leaving the country, also learn how to say “I have diabetes” and “sugar or orange juice, please” in the language or languages of the countries you’ll visit.
Insure yourself if need be. InsureMy Trip.com can help.
Many people with diabetes, particularly those who use insulin, should have a medical ID with them at all times.
In the event of a severe hypoglycemic episode, a car accident, or other emergency, the medical ID can provide critical information about the person’s health status, such as the fact that they have diabetes, whether or not they use insulin, whether they have any allergies, etc. Emergency medical personnel are trained to look for a medical ID when they are caring for someone who can’t speak for themselves.
The second rule of travel for a person with diabetes: pack at least twice as much medication and blood-testing supplies as you think you need. Pack all of them in your carry-on bag so that your medication is always with you (checked luggage can get lost). Keep a photograph of the medicines you are on in your smartphone. This will help in case the prescription is lost.
Whether you travel by car, plane, boat, bike, or foot, you’ll want to keep this “carry-on” bag with you at all times. Pack this bag with:
• all the insulin and syringes you will need for the trip
• blood testing supplies (include extra batteries for your glucose meter)
• all oral medications (an extra supply is a good idea)
• other medications or medical supplies, such as glucagon, antidiarrhoeal medication, antibiotic ointment, drugs for motion sickness.
• your ID and diabetes identity card
• a well-wrapped, air-tight snack pack of crackers or cheese, peanut butter, fruit, a juice box, and some form of sugar (hard candy or glucose tablets) to treat low blood glucose.
Eating in the Air
When you fly, you can request a special meal low in sugar, fat, or cholesterol. Make your request at least two days before the flight.
If you take insulin, wait until you see your food coming down the aisle before you take your shot. Otherwise, a delay in the meal could lead to low blood glucose. To be safe, always carry some food with you. If your meal is delayed or an order is mixed up, you won’t be stuck with an empty stomach.
I am on insulin
- When you travel with insulin, give some thought to where you’ll be storing your supplies. Insulin does not need to be refrigerated, but insulin stored in very hot or very cold temperatures may lose strength.
- Do not store your insulin in the glove compartment or trunk of your car. Backpacks and cycle bags can get quite hot in the direct sunlight. If you plan to travel by car or bike or to be out in the elements, take steps to protect your insulin. Many travel packs are available to keep your insulin cool.
- In general, you should stick with the exact brand and formulation of insulin that you have been prescribed by your doctor.
- However, if you run out while you are on the road, and your regular brand is unavailable, you may substitute another brand’s equivalent formulation (for example, NovoLog for Humalog, Humulin R for Novolin R). Changes in formulation (for example, from rapid-acting Humalog to to short-acting Humulin R) require medical supervision.
Insulin can come as U-40, U-80 U-100 and U-500. This means one ml of that insulin could have either 40 units or 80 units or 100 units or 500 units.
If you need to use these insulin preparations, you must buy new syringes to match the new insulin to avoid a mistake in your insulin dose. If you use U-100 syringes for U-40 or U-80 insulin, you will take much less insulin than your correct dose. If you use U-100 insulin in a U-40 or U-80 syringe, you will take too much insulin. However, the pen devices do not have these problems.
Crossing Time Zones
If you take insulin shots and will be crossing time zones, talk to your doctor or diabetes educator before your trip. Bring your flight schedule and information on time zone changes. Your doctor or educator can help you plan the timing of your injections while you travel.
Remember: eastward travel means a shorter day. If you inject insulin, less may be needed. Westward travel means a longer day, so more insulin may be needed.Visit www.voyagemd.com for insulin dose calculation while going on long hours. One may also need to adjust the insulin dosages when going on trekking or climbing mountains when abroad.
- To keep track of shots and meals through changing time zones, keep a watch on the home time zone until the morning after arrival.
- Keep the home time in the watch for half a day after arriving so that you take the shots of insulin at the normal time as back home. The time can be set after 8 hours.
- If on an insulin pump, change the time to new country before take off and program the pumpaccor
- If one injects insulin while in flight, those traveling frequently suggest you be careful not to inject air into the insulin bottle. In the pressurized cabin, pressure differences can cause the plunger to “fight you.” This can make it hard to measure insulin accurately.
- Checking the blood glucose while traveling is as important as when at home. Also, check the blood glucose level as soon as possible after landing.
- Jet lag can make it hard to tell if one have very low or very high blood glucose.
Welcome to a new place
After a long flight, take it easy for a few days. Check your blood glucose often. If you take insulin, plan your activities so you can work in your insulin and meals.
- If you are more active than usual, your blood glucose could go too low. Take along snacks when hiking or sightseeing. Don’t assume you will be able to find food wherever you are.
- No matter what kind of diabetes you have, it’s smart to watch what you eat and drink when traveling. Avoid tap water overseas. This includes ice cubes made from tap water.
- Ask for a list of ingredients for unfamiliar foods. Some foods may upset your stomach and hurt your diabetes control. But you will also find foods that give you a healthy taste of culture.
- Wear comfortable shoes and never go barefoot. Check your feet every day. You should look for blisters, cuts, redness, swelling, and scratches. Get medical care at the first sign of infection or inflammation.
- Go wherever your heart leads you. Just remember that you take your diabetes with you. Take your self-care along, too.
- It is always refreshing to have soda, slushies or coffee when traveling. Remember that these can have a lot of calories and carbohydrates.Try to have plain coffee with low fat milk rather than the fancy Cuppa Mocha, Starbucks or Latte which can pack quite a lot of calories. You must enjoy the vacation and so even if you wish to have all these, go for a stroll after the meals or these beverages.
- Those planning on visiting a beach, must remember to carry some cool fluids and keep the medicines cool. Those who wish to have their blood sugar checked by pricking must remember to wash their hands well before doing so. Some have alcohol while in the pool or on a beach.
- The effects of alcohol can be blunted while in water and so many may consume more to get the “kick”. Alcohol can increase the sugar levels. Cocktails can be pretty dangerous in terms of calories and sugar levels.
- Please do not walk barefoot however beautiful the beach may be.
- For those on an insulin pump, have the pump disconnected while taking off or landing as the pressure changes can sometimes deliver more insulin than needed. During the reconnection, remember that small air bubbles must be removed or else less insulin will be delivered. The extreme heat can sometimes damage the insulin in the infusion tubing which can work less effectively.
Carry the following with you to avoid problems at the airport
• Some document from the doctor mentioning you are diabetic
• A document to explain why carrying an insulin pump, glucometer, lancets for pricking blood, test strips, insulin pens and the needles, insulin storage cans or packs.
• Carry enough stock of insulin
• Quick acting carbohydrates such as glucose powder.( remember that chocolates, juices may get damaged with travel and the glucose tablet may harden)
• Slow acting carbohydrates such as biscuits or cereal bars.
• Let the flight attendant know of your diabetes as low sugar can mimic drunken behavior!
• Inform the flight attendant or airlines of your diabetes status, so they know what to do if traveling long distances. They may give you extra leg room seats.
• You can also request for a special menu which comes with some of the leading airlines.
• While flying, never aim for perfect glucose control ( keep the levels between 8 – 13 mmol/L or 144 – 203 mg/dL)
• Check the sugar levels in between if long haul flights( more than 4 hours)
Sometimes despite the intense effort and hard work put in, the weight loss is not as expected . One also tends to notice that a plateau has been hit after a period of time when the weight remains stationary. This is the dangerous time when one may give up out of frustration and all the weight lost will be regained in no time.
Given below are some of the labels on food items and what they actually mean:
|No fat or fat-free
||Contains less than 0.5 g of fat for each 100 g/ml
|Lower or reduced fat
||Contains at least 25% less fat for each 100 g than original
||Contains less than 3 g fat for each 100 g or 1.5 g for each 100 ml
|Low in saturated fat
||Contains no more than 1.5g for each 100g or 0.75g for each 100ml
|Lite or light
||Contains 25% less kilojoules than the original or comparative product
||Contains less than ½ g sugar for each 100g
||At least 25% less sugar for each serving than the original product
|No added sugar
||Sugar in any form has not been added as an ingredient
||No sugar or sweetener has been added
|No preservatives added
||Contains no added chemicals but may contain natural preservatives
||Contains less than 120 mg sodium for each 100g
|No salt or salt-free
||Contains 5 mg or less of sodium for each 100g
||Contains between 4.8 g– 6g or more fiber for each 100g
||Equal to or less than 10% of total fat
||Equal to or less than 5% of total fat
||20 mg for each 100g or 10 mg for each 100 ml
Some of the diets available are mentioned hereunder
Diet type 1 2 3 4 5
Flexibility Yes No No No No
Limitation no food is off limits single food type fat and proteins limited fat replacement meals
Physical activity Yes No Optional Yes Optional
Sustainability Yes No No No Costly, No
Diet type 1 : DASH, LEARN, TLC, Mayo Clinic, Mediterranean, Weight watchers
Diet type 2 : Fad
Diet type 3: Glycemic index diet, Nutrisystem, Sugar busters
Diet type 4: Low Fat
Diet type 5 : Meal replacement ( HMR, Jenny Craig, MEDIFAST)
DASH = Dietary Approaches to Stop Hypertension; HMR = Health Management Resources; LEARN = Lifestyle, Exercise, Attitudes, Relationships, Nutrition; TLC = Therapeutic Lifestyle Changes.
While selecting a weight loss program, it should be
• Should suit ones budget
There are many medicines and programs which claim to reduce weight. Remember that there is no short cut to weight reduction. It needs patience, support of friends and family and tremendous will power. Usually those with weight issues refrain from socializing, swimming and partying for fear of being ridiculed in public. This leads them to become introverts and they take to eating for comfort which further worsens their predicament. These people have to be coaxed and motivated into moving into a program slowly. Most of these people are fed up of being told about diet and exercise and look for short cuts. The market exploits this weakness. Remember that there is no perfect diet to reduce weight. There is must be more of expenditure of energy than the intake of food. Generally, fried food, less of salt, less of junk food, less of starch are the necessary steps. A rapid weight loss will increase the uric acid levels in many.
What causes a weight-loss plateau?
The progression from initial weight loss to a weight-loss plateau follows a typical pattern. During the first few weeks of losing weight, a rapid drop is normal. In part this is because when calories from food are reduced, the body gets needed energy by releasing its stores of glycogen, a type of carbohydrate found in the muscles and liver. Glycogen holds on to water, so when glycogen is burned for energy, it also releases water, resulting in substantial weight loss that’s mostly water.
A plateau occurs because the metabolism — the process of burning calories for energy — slows as you lose muscle. The weight-loss efforts result in a new equilibrium with a now slower metabolism.
At this new equilibrium, calories eaten equals calories expended. This means that to lose more weight, one has to either increase the level of physical activity or decrease the intake of food. Using the same approach that worked initially may maintain your weight loss, but it won’t lead to more weight loss. Some people feel they should eat more due the workout.
How can you overcome a weight-loss plateau?
If at a weight loss plateau, you may have lost all of the weight you will, given the number of calories you’re eating each day and the time you spend exercising.
• Reassess your habits. Look at the food habits and work out regimes.
• Cut more calories. Reduce your daily calorie intake by 200 calories — provided this doesn’t put you below 1,200 calories. Fewer than 1,200 calories a day may not be enough to keep you from feeling hungry all of the time, which increases your risk of overeating. In addition, this reduced calorie intake should be sustainable. If not, you’ll regain the weight you’ve lost and more.
• Step up your workout. Increase the amount of time you exercise by an additional 15 to 30 minutes. You might also try increasing the intensity of your exercise, if you feel that’s possible. Additional exercise will cause you to burn more calories. Consider adding resistance or muscle-building exercises. Increasing your muscle mass will help you burn more calories.
• Pack more activity into your day. Think outside the gym. Increase your general physical activity throughout the day by walking more and using your car less.
Maybe the weight you’re striving for is unrealistic for you. If you’ve improved your diet and increased your exercise, you’ve already improved your health even without further weight loss. For those who are overweight or obese, even modest weight loss improves chronic health conditions related to being overweight.
Whatever you do, don’t revert back to your old eating and poor exercise habits. That may cause you to regain the weight that you’ve already lost.
Remember any physical activity will go a long way to good health and lift up your mood as well. It always is good for toning up your muscles and joints rather than having to surrender to medicines.
Check weight, waist circumference of the fit of your clothes to analyze the progress. Please also remember that the weight loss may be quick initially and then it will plateau out before dropping again. The amount of weight loss per week varies from person to person and so it is obvious that the results of a certain program in which Mr or Ms A lost weight may not be enough or may be too much for Mr or Ms B. Some get bored of the monotonous diet and it is okay to cut lose once in a while. But, if it is done quite frequently, it can be enough to jolt once the sugar levels go alarmingly high which motivate the person to do better.
Exercise in any form is welcome in the quest for weight reduction. One can split the sessions to three sessions of ten minutes each rather than half an hour at one time. The post meal stroll does work well.
Summer is here again. Here, in the Middle east, there are just 2 seasons, summer and a cool season ( not exactly winter). The months from October to March are the months when the mercury drops to pleasant levels. The remaining part of the year is generally quite hot and dry. There are areas in the Middle East where the winter months can be at sub zero temperatures. Many people flock to such places to enjoy the temperature during those times. There are a lot of people from around the globe who constantly live in very cold climates and they look forward to the summer here to get a good tan or just bask in the sun. Vitamin D levels are linked to the exposure to effective sunlight. Though there is plenty of sunshine in some parts of the world , people do not go out in the sun or even if they do, they are covered in their traditional dress so that the exposed areas are minimised. Liberal usage of sunscreen lotions also plays an important role in the development of Vitamin D deficiency.
Sun screen lotions have been marketed by many companies. It is useful to know all these lotions come with a Sun Protection factor (SPF). This number measures how well that lotion will protect from harmful UVB sun rays. These do not protect from harmful UVA rays of the sun. If your skin will burn in 10 minutes of exposure to bright sunlight, a lotion of SPF 15 will protect from sunburns for 150 minutes approximately( 10 x 15). This will of course, depend on the skin type and also the activity being done in the outdoors. Please also note that a lotion of SPF 50 will not mean it will protect 2/3 times more than a lotion with SPF 30. All these lotions may be allergic for those with sensitive skin. Try out a small sample on your wrist and see if okay before purchasing. For effective sunscreen, douse on the lotion at least 30 minutes before going outdoors. Rub in a good measure till the white color of the lotion disappears. Coconut butter (available from the germinating coconut) is a good natural sunscreen. One can periodically apply the sunscreen depending on how long one will be outdoors and also depending on skin type. Cold yoghurt can help in removing the itching and irritation after getting sunburns. The skin becomes red soon after it is burnt and may start peeling off the next day. Many remain in the swimming pool to be away from the heat. But, if in an outdoor swimming pool, the part of the skin exposed may get burnt without ones knowledge until he or she gets out of water. Use wide hats, remain in the shade from time to time and hydrate well also help.
Tips handling the summer:
Hydration with fluids:
• Be well hydrated with non sugary drinks
• Stay off alcohol, caffeinated drinks, fizzy drinks and sports drinks
• Plain water is a good source of fluids- which has no calories
• Tender coconut water is good for hydration
• Pocari sweat can increase the sugar levels for many
• Watermelon juice will increase the sugar levels
• Take small frequent sips from time to time rather than a large quantity at one time.
• There are excellent mocktails made with seasonal fruits such as Pappaya, pomegranate, banana, berries with some milk and sugar if needed. People add a squeeze of lemon with mint leaves to enhance the flavor and cool the body. It need not be chilled to give a cool feeling. The throat may get inflammed by taking too cool drinks while climate is hot.
• Buttermilk is a healthy drink. Adding ginger or chillies will enhance the flavor.
• Dark sago seeds is cooling. These can be soaked for an hour or so and they swell to form light black small jelly soft globules. These can be added to the juices made at home.
This happens when one does vigorous exercise or heavy work outdoors in the sun. Muscle cramps, feeling nauseated, dizzy, having rapid heart rates and feeling very feverish can be markers pointing towards exhaustion. Some collapse due to the heat (called Heat stroke). This can be avoided by exercising in a cool place or indoors or before the temperature climbs up. Have sips of water to cool down, some even wrap a wet towel on their head or face to cool down. Have a bath in normal temperature water. Exercise at times when the sun is not hot- maybe early in the day or late in the evening.
Wear cotton based clothes which are airy and help evaporate the sweat. Dress in loose sized dress and not using skin tight clothes.
• Carry on yourself plenty of water and snacks. Carry a glucometer as well. Do check the sugar if feeling dizzy.
• Store the glucometer, test strips and insulin in cool places. Never leave them in the car in the summer. There are even times when the medicines stored in blisters do get damaged when left in the car in the heat.
• One can use an umbrella or a wide hat to shade away the heat while walking.
• The eyes and skin can become very dry due to the excess use of air conditioners especially when the draft is aimed towards the face. Use a soothening eye drops which can be prescribed by the eye doctor and moisturizing creams to make the skin moist. One may have to use these quite frequently during the day.
• Remember to keep the windows of the car down a little especially when parked in the sun and also use screens to ward off the direct sunlight.
• Normally the water coming from the water taps or that stored in the overhead tanks will be quite hot. Some even get burnt due the extreme heat of the water. This can be a problem especially among those who are diabetic and who have nerve problems which prevent them from realising the water is hot. Scalds of the private areas are even seen when washing after toilet. It is best to store water overnight in large containers to prevent this from happening.
Dietary Cholesterol is seen in all animal products such as meats, dairy products and eggs, deep fried items, processed food and some of the bakery products containing trans fats and saturated fats. Cholesterol is made in the liver and is essential to build up cell membranes, formation of sex hormones and form bile acid which help in digestion of fats.
Diabetes has long been considered a risk factor for developing a heart disease. The risk is approximately 2 to 4 times more than those without diabetes getting a heart disease. 65% of the deaths among those with diabetes are related to heart diseases. However, even among those with diabetes, the risk varies among individuals and is influenced by gender, duration of diabetes , presence of raised blood pressure, poor cholesterol control and smoking history. The elder the patient, the higher is the risk for developing a heart disease. Among the fairer sex, the protective effect of estrogen can prevent a heart disease till they stop menstruating. Having a higher body mass and high uric acid levels are also known to trigger heart diseases.
Though maintaining normal or near normal sugar levels can improve the outcome of diabetes in general, good control prevents the progression of or delays the onset of microvascular complications such as the eye, kidney and nerve damage ( retinopathy, nephropathy and neuropathy). However, tight control of the blood pressure and cholesterol levels are important in preventing the progression to or delay the onset of developing macrovascular complications such as stroke, blood vessel diseases of the legs and heart attacks.
The cholesterol panel ( Lipid profile) is generally done after a 12 hour fasting. The blood is collected and the total cholesterol, triglycerides, LDL cholesterol, HDL cholesterol, ratio of cholesterol to HDL and LDL to HDL cholesterol is measured. The HDL cholesterol is the good cholesterol. The ratios mentioned above indicate the tendency to develop a block in the blood vessel. Cholesterol can get deposited in the inner linings of the blood vessels causing varying degrees of blocks. The blood vessel involvement is diffuse among those with diabetes and it has also been shown that numbers of collateral blood vessels are reduced among those with diabetes. The plaque which consists of the cholesterol deposit, can get dislodged and travel in the blood causing blocks elsewhere from its origin. Having pre diabetes, especially the increased glucose levels after meals only ( called IGT) is also a risk for developing a heart disease.
Better investigative modalities and better awareness among the people have helped improve the outcome, but because of sedentary lifestyle and enhanced use of junk food, high cholesterol levels and even heart attacks are quite common among the young.
But, when levels of cholesterol are high, it can get deposited in walls of arteries( blood vessels carrying blood from heart) . Normal levels < 5.2 mmol/L
HDL C ( High density lipoprotein cholesterol) is called the good cholesterol. This transports cholesterol from the blood and artery walls to the liver where it gets converted to bile which help in digestion of fats. Risk of coronary heart disease increases by 2-3% for every 1.0 mmol/L fall in levels of HDL C. Normal level > 1.0 mmol/L.
LDL C ( Low density Lipoprotein cholesterol) is called the bad cholesterol. This helps to transport cholesterol to various body cells and deposit the excess in walls of the arteries. Normal levels < 1.7 mmol/L if diabetic or < 2.3 mmol/L if not diabetic.
The cholesterol can get deposited on the inner linings of the blood vessels causing blocks in the eyes, heart supplying blood vessels, brain and kidneys causing blindness, heart attacks, strokes or paralysis, erectile dysfunction among males and kidney failure.
According to the data available with the various governing bodies around the globe, for every 10 mg/dL or 0.25 mmol/L increase of HDL, the good cholesterol, the risk for developing a heart attack is reduced by 2-3%. Similarly for every 1 mmol/L or 88.7 mg/dL increase of triglyceride level, the risk of developing a heart disease increases by 30% among men and 75% among women.
The main cholesterol level to be kept under control is the LDL cholesterol. The lower the level of LDL, less is the risk to develop a heart attack. Similarly, higher the HDL, the protective cholesterol, better is the outcome.
Non pharmacological ways to improve the HDL levels and reduce the LDL levels:
• Reduce smoking
• Increased consumption of avocados, a handful of non roasted non salted dry nuts( walnuts, almonds, pistachios).
• Olive oil or canola oil to be taken
• Reduction or avoiding red meat ( mutton, beef, pork, organ meat such as liver, gizzard)
• Reduction of deep fried food items
• Reduced intake of prawns, crabs and lobster.
• Reduced intake of full cream dairy products
When to treat with medicines?
When lifestyle modification and diet control alone do not help in lowering the levels, one will have to reconsider options of pharmacotherapy.
Guidelines from around the world have stressed the need for treatment with medicines in the following groups of people:
• If aged between 40-75 years with >7.5% risk of developing a heart attack in the next ten years
• If aged < 40 years with LDL cholesterol levels >190 mg/dL
• If person has suffered from any of the following:
• Heart attack
• Stroke or paralysis
• Transient ischemic attack ( features of stroke which reversed due to incomplete block to blood flow to brain)
• Those with peripheral artery disease of the extremities
• Those who have undergone revascularization procedures to improve blood flow in either heart or extremities
The risk for developing a heart attack is estimated by the health care professionals by using calculators incorporating ones race, gender, age, total cholesterol, LDL cholesterol, HDL cholesterol, blood pressure, use of medicines for controlling blood pressure, smoking and diabetes mellitus.
Normally the lipid profile ,which tests the various cholesterol types, is done after a 12 hour fasting. There are tests also which are available to assess how much of cholesterol has already lined the vessels. ( coronary angiogram, coronary calcium scoring and carotid doppler) Check the lipid levels once in 3 months if the levels are high or else once in 6 months. The doctor will advise when to start the medicines and if needed, when to stop the medicines. Some of the tests done to check heart functioning will also indirectly determine the lining of the vessels supplying the heart.( ECHO cardiogram and Stress Treadmill testing)
Statins, fibrates and drugs which reduce absorption of cholesterol from the intestines,ezetimibe, are used in treatment of high lipid levels. The former group is generally used around the world. Niacin is still being used in some parts of the world
A note on statins
Statins are generally found to have some side effects such as muscle pain and altered liver enzyme levels. It has also been associated with a 0.5% increase in chance in developing diabetes which led to a scare among the patients and health care providers.
However, statins have benefits besides lowering cholesterol levels, statins also help in stabilizing the plaque formation , reducing the inflammation of the blood vessels and regression of blocks to an extent. The plaque which is a mixture of calcium, lipids,fats and blood elements can get “fractured” and can shower small blocks through the blood vessels which can cause block at distant sites.
The benefits of taking a medicine to lower cholesterol far outweigh the risks associated with the medicine.
The benefits of taking medicines to control cholesterol go along way beyond just control of high levels. Cholesterol deposition almost always occurs in the inner lining of the blood vessels. People of some races are more prone for developing heart attacks when compared to people of other races. Some people inquire if they can stop the medicines for cholesterol once the levels are normal. Being a diabetic, the chances of getting a heart attack are high and so taking this tablet will go a long way to prevent the onset of developing a serious heart disorder. If intolerant to statins, there are other classes of medicines which can be used to control the cholesterol levels.
Some of the commonly used statins are Simvastatin, Fluvastatin, Atorvatstain and Rosuvastatin.
The dose needed depends on the treating health care professional and the need for starting the treatment as to whether it was for prevention or for treatment. If high doses are needed, the side effects can be minimized by addition of ezetimibe ( drug to impair absorption of cholesterol from intestines) or fibrates.
The liver enzyme levels and muscle enzyme level are checked frequently after starting therapy. A baseline level of the above enzymes are taken in some centers before commencing therapy.
The triglyceride levels are high among the Asians and South Indians due to their dietary habits and genetic make up. However among those in the rest of the world, LDL levels are high and targeted for control.
Exercise and impact on cholesterol
Link between coronary heart disease and cholesterol levels are well established through various studies.
Sedentary lifestyle adds to the risk for development of heart problems.
It has been shown by various studies that men who exercised more 75% of the maximum heart rate ( 220-age in years) at least 3 times a week for 12 weeks have reduced risk for developing heart disease. However, such studies have not been done on women.
In post menopausal women benefits of exercise were seen among those who exercise for 70% maximum heart rate for 24 weeks and who were on hormone replacement therapy. It was shown low to moderately intense exercise among post menopausal women improved outcomes.
The intensity, duration and frequency of exercise, the initial HDL C levels and length of the training period determine the benefits of exercise on cholesterol levels.
Exercising regularly for 8 months or jogging for 6 months or 3 weeks of diet control or brisk walking for three months can help reduce the LDL cholesterol. 5-10% body weight reduction can reduce the cholesterol levels. Recommendation is 150 minutes of moderate exercise or 1000 Kcals to be burned per week.
Omega 3 capsules taken once daily( containing fish oil) help to reduce a triglyceride levels to an extent. For the vegetarians, flaxseeds can be taken in place of Omega 3 capsules. There are no studies establishing the benefits of taking this to prevent heart attacks or strokes.
The diet should contain- 50-60% of total calories as carbohydrates, < 30% as fats, 15% as proteins, < 10% as polyunsaturated, < 20% as monounsaturated and 20-30 g of dietary fiber.
A note on oils.
Replacing saturated and transfats with monounsaturated and polyunsaturated fatty acids can help improve the cholesterol levels.
If monounsaturated acids are used, there is a 12% reduction in total cholesterol and 15% reduction in LDL cholesterol. If polyunsaturated acids are used, cholesterol reduction by 19% and LDL by 22% is observed in studies.
Monounsaturated fatty acids are always better than polyunsaturated oils.
Remember that any oil when it is boiled loses its good properties. Hence, even olive oil or canola oil will not do any good if they are boiled.
Olive oil comes as extra virgin type and Pomace type. The extra virgin is used for raw consumption and the pomace type for cooking. Olive oil is actually the juice of olives unlike most of the oils made from the seeds.